Physician Neglects To Perform MRI On Patient With Symptoms Of Multiple Sclerosis

This case involves a healthy female patient who presented with tingling in her legs and episodes of blurry vision and eye pain. The physician suspected multiple sclerosis and performed a CT. The CT read as negative and no further workup or follow up was performed. Over the next 4 months, the patient had recurring and worsening symptoms, particularly in her legs. The patient returned to the hospital after an acute flare-up in her leg numbness caused her to lose her balance and fall. The neurologist who saw the patient immediately performed an MRI which revealed the patient had several multiple sclerosis plaques. A few years after receiving her diagnosis, the patient experienced difficulty swallowing and frequent hand tremors. An expert in neurology was sought to opine on the standard of care for patients who present with symptoms of multiple sclerosis and discuss how a delay in diagnosis and treatment can impact the outcome of such patients.

Question(s) For Expert Witness

1. Briefly describe your experience treating patients with multiple sclerosis.

2. What is the standard of care for initiating treatment of a patient with one episode of multiple sclerosis symptoms?

3. If treatment is not initiated after one episode, what is the standard of care in terms of referral to a specialist for monitoring symptoms?

4. How can delay in treatment impact outcome in patients with multiple sclerosis?

Expert Witness Response E-101192

I care for about 150 MS patients in an ongoing way and therefore I am very familiar with the standard of care and protocols for treating MS patients and diagnosing MS. If MS was suspected in the early presentation, then a CT scan is entirely inadequate for evaluation and an MRI should have been performed. A patient with a single attack typical of MS may have either MS or so-called clinically isolated syndrome (CIS), which is diagnosed depending on other features of the exam and history. The standard of care for probable or definitive MS is to start a disease-modifying therapy. The standard of care in CIS is less clear and is an evolving question. Most MS specialists would treat CIS if it is high risk. In this particular case, it depends a lot on the specific presentation, history, and MRIs. If no MRI was done initially then the evaluation was very substandard. If a patient with CIS or suspected MS isn't treated, then screening MRIs are indicated at regular intervals to make sure there is no further radiologic evidence of injury. Disease-modifying therapies decrease the rate of relapses in MS and relapses can have permanent sequelae. In addition, long-term treatment with these drugs decreases the long-term accumulation of disability.